Transcription of Application for Extension Enrollment - Office of the Registrar
1 Enrollment & ACADEMIC SERVICES Office OF THE Registrar Application for Extension Enrollment This form can be filled out with Adobe Acrobat and then printed for signatures. Upon completion, this form should be returned to Texas A&M University, Office of the Registrar , Records Section, Box 30018, College Station, TX 77842-3018; or General Services Complex, Suite 1501. Any questions may be directed to 979-845-1003 or Updated: March 2018 Please answer all questions. Please print legibly. Student Name: Last First Middle M F Are you currently seeking a degree or certificate from Texas Student s ID (if known) Gender A&M University? Yes No Ethnicity: American Indian/Alaskan Native Asian/Pacific Islander Black/non-Hispanic Hispanic White, non-Hispanic Other Country of Citizenship: Mailing Address: City, State, Zip Code Date of Birth: Month/Date/Year Place of Birth: City, State, County Previous Institutions Attended Please list all colleges/universities attended including previous attendance at Texas A&M and Extension courses College/University Dates of Attendance Degree(s) Awarded Directory Information Release Restrictions The following is considered directory information by Texas A&M University and may be released outside the University unless restricted by the student.
2 Please check any information categories you wish to restrict. Name Program of Study (College, Major, Campus) Address (Local) Dates of Attendance Address (Permanent) Previous Education Agencies/Institutions Attended Telephone Number (Local) Participation in Officially Recognized Activities & Sports Telephone Number (Permanent) Degrees Honors, & Awards Received Email Address Classification Student Signature Date Enrollment & ACADEMIC SERVICES Office OF THE Registrar Application for Extension Enrollment This form can be filled out with Adobe Acrobat and then printed for signatures. Upon completion, this form should be returned to Texas A&M University, Office of the Registrar , Records Section, Box 30018, College Station, TX 77842-3018; or General Services Complex, Suite 1501.
3 Any questions may be directed to 979-845-1003 or Updated: March 2018 For Department/ Extension Course Office Use Only Extension Course Enrollment Beginning Date: Ending Date: Campus: Last Name: First Name: Middle Name: Subject Course Section Hours Course Title Grade Professor (Printed Name) Signature Date
